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IMPORTANT - THIS IS NOT A BILL. SEND NO MONEY UNLESS STATEMENT IS ENCLOSED. <br />HOME OFFICE SAN FRANCISCO POLICY DECLARATIONS <br />CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY <br />THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON. <br />THIS INSURANCE IS EFFECTIVE FROM <br />12:01 A.M., PACIFIC STANDARD TIME <br />8-26-21 TO 8-26-22 AND SHALL <br />AUTOMATICALLY RENEW EACH 8-26 <br />UNTIL CANCELLED <br />CONTINUOUS POLICY9304403-21 <br />ELITE SPECIAL EVENTS, INC DEPOSIT PREMIUM <br />11278 LOS ALAMITOS BLVD <br />LOS ALAMITOS, CALIF 90720 MINIMUM PREMIUM <br />PREMIUM ADJUSTMENT PERIOD <br />NAME OF EMPLOYER- ELITE SPECIAL EVENTS, INC (A CORP) <br />TRADE NAMES- ELITE SPECIAL EVENTS, INC <br />LOCATIONS• 11278 LOS ALAMITOS B <br />CYPRESS CA 90720 3958 <br />$0.00 <br />$1,400.00 <br />QUARTERLY <br />N SP <br />1. WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE <br />WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA. <br />2. EMPLOYER'S LIABILITY INSURANCE - PART TWO OF THIS POLICY APPLIES TO <br />LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR <br />LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS, <br />$1,000,000 <br />CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE FROM 08-26-21 TO 08-26-22 <br />INTERIM <br />PREMIUM BASE BILLING <br />BASIS RATE RATE* <br />9095-1 EVENT MARKET, FESTIVAL OR TRADE SHOW 30000 9.24 9.99 <br />OPERATION --ALL EMPLOYEES--N.D.C. <br />********BUREAU NOTE INFORMATION******** <br />TED HOLCOMB P 50 $ <br />TOM MOORE CEO,S 50 % <br />TOM MOORE T 0 $ <br />FEIN 260747948 <br />TOTAL ESTIMATED ANNUAL PREMIUM $2,997 9' 1' <br />REVIEwmSA7Pkov®Br i <br />`ry <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO AUGUST 30, 2021 PO: <br />�— R¢k Mana emen[S en.Yn[ -' <br />SCIF FORM 10981A IREV.7-20161 !OVER PLEASE) 9 P 'i <br />